Home / Treatments / Coronary Artery Calcium Scoring
Coronary Artery Calcium Scoring denials: what the review data shows
Independent reviewers have decided 15 published cases where an insurer denied Coronary Artery Calcium Scoring — and they overturned the insurer 13.3% of the time. A denial for Coronary Artery Calcium Scoring is a starting position, not a final answer.
Published decisions
15
2001–2026
Overturned
13.3%
2 denials reversed
What the insurer actually argued
Denials fall into different categories, and they don’t succeed equally — so the reason on your letter changes how you should answer it.
| Reason given | Decisions | Overturned |
|---|---|---|
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 10 | 10% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 5 | 20% |
Typical time to a decision
21 days
Most land between 21 and 22 days
Handled as urgent
6.7%
Expedited when a delay would cause harm
What the reviewers wrote
Excerpts from the independent reviewers’ published findings — the actual reasoning, quoted, not summarised.
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: An enrollee has requested computed tomography (CT) of the heart without dye with quantitative evaluation of coronary calcium for evaluation of her medical condition. Findings: Two physician reviewers found that the requested services are likely to be more effective for this patient than other available options. There has been growing evidence on the use of coronary artery calcium (CAC) screening in better-studied cohorts of patients and asymptomatic individuals. CAC scoring has an increasingly high level of quality evidence on its role in risk stratification of asymptomatic patients. The accumulating evidence suggests that asymptomatic individuals with an intermediate Framingham risk score (FRS) may be reasonable candidates for coronary heart disease testing using CAC as a potential means of modifying risk prediction and altering therapy.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for cardiac calcium score computerized tomography (CT) scan. The American College of Cardiology (ACC) and American Heart Association (AHA) guidelines on the prevention of cardiovascular disease note that coronary artery calcium scoring (CACS) may valuable, actionable information. This is particularly if the CACS is zero, which would obviate the need for lifelong statin therapy or treatment with a proprotein convertase subtilisin/kexin type 9 serine protease (PCSK9) inhibitor. Conversely, an elevated CACS may reclassify the patient’s cardiovascular risk upward and justify the benefit of lifelong statin therapy, or possibly a PCSK9 inhibitor in the case of this patient, who is statin intolerant.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for computed tomography (CT) of the heart, without contrast, with quantitative evaluation of coronary calcium. The American College of Cardiology (ACC) and American Heart Association (AHA) guideline on the management of blood cholesterol supports the use of coronary artery calcium (CAC) scoring in the decision to withhold, postpone, or initiate statin therapy in non-diabetic intermediate and select borderline risk patients who lack atherosclerotic cardiovascular disease (ASCVD) risk-enhancing factors. Statin therapy is known to promote calcification of soft atheromatous plaque, thus leading to more stable, lower-risk compositions. This is often associated with an acceleration of the Agatston CAC score. As such, the prognostic utility of CAC for statin-treated patients is not well characterized.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage computed tomography (CT) scan to measure calcium in the coronary arteries. Primary prevention of arteriosclerotic cardiovascular disease requires attention to prevention and management of arteriosclerotic cardiovascular disease risk factors. Elevated serum cholesterol, usually defined by low-density lipoprotein (LDL) cholesterol, is a major arteriosclerotic cardiovascular disease risk factor. A patient’s 10-year arteriosclerotic cardiovascular disease risk should guide therapeutic considerations in patients ages 40 to 75. The higher the estimated arteriosclerotic cardiovascular disease risk, the more likely the patient will benefit from evidence-based statin treatment.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
How to use this in your appeal
These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Coronary Artery Calcium Scoringwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY
Not legal or medical advice. Coverage Rights is a self-help tool that helps you prepare your own appeal. For advice about your specific situation, talk to a licensed attorney or your doctor.